Provider Demographics
NPI:1346249315
Name:HUMPHRIES, STEFAN G (MD)
Entity Type:Individual
Prefix:
First Name:STEFAN
Middle Name:G
Last Name:HUMPHRIES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3152 LITTLE RD # 162
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-1864
Mailing Address - Country:US
Mailing Address - Phone:847-289-5727
Mailing Address - Fax:
Practice Address - Street 1:301 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5167
Practice Address - Country:US
Practice Address - Phone:386-231-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14305208100000X
CO37261208100000X
AZ26359208100000X
FLME148755208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
10384750OtherCAQH
CO22137246Medicaid
NV1346249315Medicaid
CO22137246Medicaid
10384750OtherCAQH
NV1346249315Medicaid